The Cost of Implementing and Sustaining the COMprehensive Post-Acute Stroke Services Model

Abstract

Background: The COMprehensive Post-Acute Stroke Services (COMPASS) model, a transitional care intervention for stroke patients discharged home, was tested against status quo postacute stroke care in a cluster-randomized trial in 40 hospitals in North Carolina. This study examined the hospital-level costs associated with implementing and sustaining COMPASS.

Methods: Using an activity-based costing survey, we estimated hospital-level resource costs spent on COMPASS-related activities during approximately 1 year. We identified hospitals that were actively engaged in COMPASS during the year before the survey and collected resource cost estimates from 22 hospitals. We used median wage data from the Bureau of Labor Statistics and COMPASS enrollment data to estimate the hospital-level costs per COMPASS enrollee.

Results: Between November 2017 and March 2019, 1582 patients received the COMPASS intervention across the 22 hospitals included in this analysis. Average annual hospital-level COMPASS costs were $2861 per patient (25th percentile: $735; 75th percentile: $3,475). Having 10% higher stroke patient volume was associated with 5.1% lower COMPASS costs per patient (P=0.016). About half (N=10) of hospitals reported postacute clinic visits as their highest-cost activity, while a third (N=7) reported case ascertainment (ie, identifying eligible patients) as their highest-cost activity.

Conclusions: We found that the costs of implementing COMPASS varied across hospitals. On average, hospitals with higher stroke volume and higher enrollment reported lower costs per patient. Based on average costs of COMPASS and readmissions for stroke patients, COMPASS could lower net costs if the model is able to prevent about 6 readmissions per year.

Figure 1.. Annual COMPASS Cost Per Enrollee and Per-Protocol Enrollment, by Site.

This scatter plot shows the annual per-protocol enrollment and per-enrollee cost in dollars for each hospital included in the analysis. Hospitals are stratified into four categories – 1) large (>=400 annual stroke patients) primary stroke centers (PSC); 2) small (<400 annual stroke patients) PSCs); 3) large (>=165 annual stroke patients) non-PSCs; and 4) small (<165 annual stroke patients) non-PSCs. A fractional-polynomial line was fit to the scatter plot to show the relationship between enrollment and per-enrollee costs.

Figure 2.. Per-patient Annual Costs, by Hospital Characteristic.

Box-and-whisker plots show the median, interquartile range, and range values for per-patient annual costs in dollars by four observed hospital characteristics – 1) phase of COMPASS implementation; 2) small or large, defined by annual stroke patient volume; 3) primary stroke center status; and 3) metropolitan vs. non-metropolitan status. Outliers (i.e., values beyond 1.5 times the interquartile range) are depicted as dots.